Care of the Acutely Ill Revision Guide PDF

**Care of the Acutely Ill Revision Guide** **[ABCDE Approach]** Airway, Breathing, Circulation, Disability, Exposure A systematic approach to assess and treat an acutely unwell/deteriorating patient. When using this approach it is important that you do not progress until each stage is completed a...

**Care of the Acutely Ill Revision Guide** **[ABCDE Approach]** Airway, Breathing, Circulation, Disability, Exposure A systematic approach to assess and treat an acutely unwell/deteriorating patient. When using this approach it is important that you do not progress until each stage is completed and its safe to move on. ISBAR handover tool: Identity, Situation, Background, Assessment, Recommendation NEWS2: Respiratory Rate, Heart Rate, Blood Pressure, 02 saturations, Temperature, ACVPU , On oxygen? This tool should be used in conjunction with own clinical judgement. Using the National Early Warning Score (NEWS/NEWS 2) in different Intensive Care Units (ICUs) to predict the discharge location of patients \| BMC Public Health \| Full Text **Airway:** Assessing the airway is always the first procedure carried out in an acute situation. An obstructed airway is a medical emergency requiring immediate intervention. ***Recognising Airway Obstruction*** Airway can be assessed by looking at the patient: pattern of breathing? are the conscious? are they able to speak? Note the use of any accessory muscles (scalene, trapezius, sternocleidomastoid) and changes to skin colour Airway can be divided into the upper and lower airway - Upper airway- Nose, oral cavity, pharynx, larynx - Lower airway- Trachea, bronchi, bronchioles The airway may be partially or completely obstructed - Partial airway obstruction is noisy - Stridor-caused by laryngeal spasm or obstruction - Expiratory wheeze- suggests constriction or spasm of the lower airway - Gurgling-suggests liquid in upper airway - Snoring-the pharynx is semi-occluded by tongue - Complete airway obstruction is silent - May result in Paradoxical (see-saw) breathing where the chest draws in and abdomen distends on inspiration with the reverse on expiration ***Causes of Airway Obstruction*** May be caused by external pressure or internal blockage External Pressure - Swelling of the soft tissues of the neck - Tumours of the neck - Enlarged thyroid or local lymph glands - Physical pressure on the neck (strangulation) Internal Blockage (more common) - Vomit, blood secretions, inhaled foreign body - Swelling of the airway (eg allergic response) - Blockage by tongue in unconscious patient (common) ***Management of airway*** - Head tilt, chin lift (do not use if risk of cervical injury) - Jaw thrust - Airway adjuncts - Oxygen *In case of choking* - Ask patient to cough - If cough ineffective deliver 5 back blows followed by 5 abdominal thrusts - If patient is unconscious, start CPR *In case of blood or vomit* - Gentle suction using wide bore suction device *Simple Airway Adjuncts* - Oropharyngeal Airway - Only for use in unconscious patients as may stimulate gag reflex and induce vomiting - Come in variety of sizes. To ensure correct sizing bite block should be placed at level of incisors and reach angle of the jaw - Should be inserted upside down, then rotated 180 degrees once it has made contact with the back of the throat - Nasopharyngeal Airway - Useful for conscious patients, doesn't stimulate gag reflex. Should not be used in patients with suspected basal skull fracture - Inserted into nasal passage and sits just above epiglottis - Sized by measuring earlobe to tip of nostril. Flange should sit just below nostril - Nose should be inspected for polyps prior to insertion - Lubricant should be used - If resistance felt do not continue, try other nostril *Artificial Airways* Intended for more long term use. Secures the airway and protects from aspiration - Laryngeal mask Airway - Supraglottic airway device, meaning it is placed above the level of the glottis - Quick and easy to place - Inflatable cuff allows for isolation of the trachea, reducing the risk of aspiration - For use in patients who are unconscious or heavily sedated - Endotracheal Tube Intubation - Gold standard for secure artificial airway - Inflated cuff reduces risk of aspiration - May be inserted orally or nasally. Nasal intubation preferred for prolonged intubation - Enables positive pressure ventilation - Insertion is highly skilled and should only be done by trained staff - Requires ICU care - Used in unconscious of heavily sedated patients *Tracheostomy* Surgical procedure to create an artificial opening(stoma) in anterior wall of trachea, just below cricoid cartilage. Small curved tracheostomy tube inserted. - Indications for tracheostomy - Airway maintenance - Airway protection - To enable suctioning of secretions - Weaning from ventilation - There are a variety of different tracheostomy tubes available - Cuffed-provides a seal in the trachea to protect the lungs, no air passes through upper airway. - Uncuffed-air moves through and around the tracheostomy tube - Fenestrated- has holes in outer cannula allowing air to pass through vocal cords (patient can speak) - Tracheostomy tube: Care issues - Emergency protocols must be in place to maintain patency of upper airway - Essential tracheostomy equipment must be at patients bedside at all times - Humidification is essential - Inner cannula must be regularly changed and cleaned (4 hrly) - Cuff pressure must not exceed 25cm H20 to prevent permanent damage to trachea - Communication-cuff must be deflated before speaking valve placement to prevent airway occlusion (blockage) - Regular suction - Site to be cleaned and dressed daily - Tube must be changed at least every 30 days ***Anaphylaxis*** *Main causes* - Foods: peanuts, tree nuts, shellfish, cows milk - Medications: antibiotics, contrast, chlorhexidine, NSAIDS, some chemotherapy drugs - Insect stings: bees or wasps *Symptoms* - Life threatening Airways, Breathing or Circulation autoimmune reaction. May present with or without typical skin symptoms *Management* - Get help. This is a medical emergency (999 in community, 6666 in hospital) - Position patient lying down with or without legs elevated - Administer adrenaline (1:1000) - Give fluids - If symptoms persist give 2^nd^ dose of adrenaline after 5 minutes **Breathing:** ***Relevant vital signs*** - Respiratory rate. Significant predictor of risk of deterioration. Should be counted for 1 full minute. Normal Range 12-20 bpm. While taking RR chest should be inspected for bilateral equal expansion - Sp02. Operates on two scales for target saturations. 94%-98% (general population) 88%-92% (C02 retainers eg COPD) RATES mnemonic for respiratory assessment: Respiratory rate, Auscultate chest, Trachea alignment, Effort of breathing, Sp02 ***Indicators of respiratory distress*** - Use of accessory muscles (scalene, trapezius, sternocleidomastoid) - Central cyanosis - Paradoxical breathing - Leaning forward in tripod position - Inability to complete sentences in one breath - Audible wheeze - Rapid shallow breathing - Mouth breathing, pursed lip breathing ***Respiratory Failure*** Can be divided into 2 categories - Respiratory Failure type 1: Lung failure. - Inadequate alveolar ventilation caused by either V/Q mismatch (abnormal ratio between ventilation and perfusion) Or Shunt (left-right) - Characterized by profound hypoxemia (\ - ECG may be 3, 5 or 12 lead and measure the electrical activity of the heart - 3 lead, best for continuous cardiac monitoring - 12 lead, gold standards, provides most complete and accurate results - Printed on graph paper, square 1mm each. 1s is 5 large squares/25 small squares - Normal ECG waveform consists of a number of components - P wave - Depolarisation of atria - PR interval - How quickly electrical impulses travel through AV node - QRS complex - Depolarisation of ventricle and beginning of ventricular contraction - ST segment - End of ventricular depolarisation and beginning of ventricular repolarisation - T wave - Ventricular repolarisation - QT interval - Time taken for heart muscle to contract and recover ***Resuscitation*** - 80% of patients show signs of deterioration before cardiac arrest - Chain of prevention: education, monitoring, recognition, call for help, response - Any reversible causes of cardiac arrest must be identified and treated promptly ***Bystander CPR*** - Assess and secure environment - Check for response - Call for help (999, nearest defib) - Check for signs of life (10 seconds) - Secure airway (head tilt, chin lift/jaw thrust) - Begin CPR at a rate of 30 chest compressions/2 rescue breaths. 120bpm - Continue until help arrives/casualty shows signs of life/physical can't continue ***Causes of Cardiac Arrest*** The 4 Hs and 4Ts - Hypoxia: low blood oxygen - Hypovolemia: loss of fluid volume. Most commonly caused by massive haemorrhage - Hypothermia: low body temperature - Hypo/erkalemia: electrolyte imbalance. Ka (potassium) imbalance, normal Ka range 3.5-5.5 mmols. Caused by acute kidney disease. Treatment included sodium bicarbonate - Tension pneumothorax: Air in pulmonary space. Causes deviated trachea. Medical emergency, pressure must be relieved by puncturing chest in the \*\*\* intercostal space - Thrombosis: embolism causing blockage. Most common cause of cardiac arrest. - Tampanade: fluid in cardiac sac. Pressure on cardiac muscle causes failure. - Toxins: eg overdose of opiods causes CNS depression leading to cardiac arrest, antidote: naloxone +-----------------------+-----------------------+-----------------------+ | | **Recognition/things | **How to treat it** | | | to look out for** | | +=======================+=======================+=======================+ | Hypoxia | Confusion | Sp02 monitoring | | | | | | Low blood oxygen | Tachycardia | \*Be aware of target | | | | Sp02 | | | Tachypnea (rapid, | | | | shallow breathing) | Oxygen therapy | | | | | | | Changes in skin | 15L 100% with | | | colour (blue or | non-rebreather | | | cherry red) | (reservoir) mask | | | | | | | Coughing/wheezing | | | | | | | | Sweating | | | | | | | | Fatigue | | | | | | | | Anxiety | | +-----------------------+-----------------------+-----------------------+ | Hypovolaemia | Loss of \20% blood | Control hemorrhage | | | volume | | | Loss of fluid volume | | \*remember, may be | | | Pale skin | internal | | | | | | | Sudden anxiety | Stabilize blood | | | | volume | | | Cool to touch, low | | | | temperature | IV crystalloids | | | | | | | In and out of | Blood transfusion | | | consciousness | | | | | | | | Sweating | | | | | | | | Cyanosis | | | | | | | | Tachypnea | | | | | | | | Capillary | | | | refill-prolonged | | | | (\>2s) | | | | | | | | Blood pressure-low | | | | | | | | Heart rate-fast | | | | | | | | ABG | | | | | | | | Decreased urine | | | | output | | +-----------------------+-----------------------+-----------------------+ | Hyperkalaemia | Tall T waves on 12 | Protect heart- | | (hypokalaemia, | lead ECG | calcium chloride | | hypoglycaemia, | | | | hypocalcaemia etc) | U and E blood test | Shift potassium into | | | (Normal Ka range | cells- insulin and | | Electrolyte imbalance | 3.5-5.5 mmols) | glucose IV infusion, | | | | sodium bicarbonate, | | | Use point of care | beta 2 agonist eg | | | blood gas analyser if | salbutamol | | | available | | | | | Consider dialysis to | | | | remove potassium from | | | | body | +-----------------------+-----------------------+-----------------------+ | Hypothermia | Assess core | Remove wet clothes | | | temperature using low | | | Low body temperature | reading thermometer | Foil blankets | | | | | | \7 days. Doesn't stop without treatment - Permanent- lasts \>1 year. Medication doesn't return to normal sinus rhythm - Treatment - Rate control- beta blockers, digoxin - Rhythm control- cardioversion with drugs eg amiodarone - Anticoagulation- warfarin, apixaban ***Acute Kidney Injury*** AKI: Oliguria (low urine output \65 - Increasing NEWS\ Hypovolemia - Nephrotoxic drugs, DAMN: Diuretics, Ace Inhibitors, Metformin, NSAIDs - Sepsis - Iodine contrast Potential outcomes - Cardiac arrythmias, K+ \>6mmols - Pulmonary and peripheral oedema - Metabolic acidosis - Elevated urea leading to seizure, coma, arrest - Haematuria/proteinuria - Anaemia - Haemodynamic instability Nursing Management - ABCDE assessment - Knowledge of risk factors - Normal serum range knowledge - Urea 2.5-6.6 mmol/L - Creatinine 55-120 umol/L - GCS assessment - Supplemental 02 to maintain target range - Vasopressors may be needed - Query IV fluids - If hyperkalemic note peaked T waves on ECG ***Acute Gastrointestinal Problems*** +-------------+-------------+-------------+-------------+-------------+ | | Site | Radiation | Aggravating | History | | | | | Factors | | +=============+=============+=============+=============+=============+ | Appendiciti | Epigastric | | Movement, | Worsens in | | s | (upper, | | coughing | 1^st^ | | | middle) | | | 24hrs, | | | | | | migrates to | | | | | | right iliac | | | | | | fossa | | | | | | (lower | | | | | | right), | | | | | | Becomes | | | | | | constant | | | | | | and sharp | +-------------+-------------+-------------+-------------+-------------+ | Diverticuli | Left iliac | | Movement | Older | | tis | fossa ( | | | patient, | | | lower left | | | recurrent | | Inflammatio | | | | pain | | n | | | | | | of | | | | | | irregular | | | | | | bulging | | | | | | colon | | | | | +-------------+-------------+-------------+-------------+-------------+ | Obstruction | Symmetric | | Meals | Severe | | | | | | pain, may | | | | | | start as | | | | | | sub-acute | +-------------+-------------+-------------+-------------+-------------+ | Perforation | Upper | | Movement | Acute | | | | | | history | | Hole in | | | | | | wall of | | | | | | digestive | | | | | | tract | | | | | | | | | | | | \*Think | | | | | | sepsis | | | | | +-------------+-------------+-------------+-------------+-------------+ | Cholecystit | Right upper | Shoulder, | Inspiration | Recurrent | | is | quadrant | back | | bouts of | | | | | | colic | | Inflammatio | | | | | | n | | | | | | of | | | | | | gallbladder | | | | | +-------------+-------------+-------------+-------------+-------------+ | Pancreatiti | Central, | | Movement | Severe | | s | upper | | | pain, may | | | | | | be acute on | | Inflammatio | | | | chronic | | n | | | | | | of pancreas | | | | | +-------------+-------------+-------------+-------------+-------------+ | Renal Colic | Flank | groin | | Acute, | | | (side) | | | severe pain | | Acute pain | | | | | | caused by | | | | | | urinary | | | | | | stones | | | | | +-------------+-------------+-------------+-------------+-------------+ **Disability:** **Key assessments/measurements** - Blood glucose (normal range 4-8mmols) - Glasgow Coma Scale (Score 3-15 Measurement: Eyes, Verbal, Motor) - A(C)VPU-Alert, Confusion (new), Voice, Pain, Unresponsive - Pupils (PEARL, Pupils equal and reactive to light) ***Acute endocrine problems (Diabetic)*** ***Diabetic Ketoneacidosis (DKA)*** Diagnosis - BM \>11mmol/L OR diabetes diagnosis - Ketones \>3mmol/L - Bicarbonate \